Kenneth Levy

Pennsylvania State University | Penn State · Department of Psychology

In response to Cannon's (1929) widely accepted fight-or-flight system, Taylor et al. (2000) proposed the tend-and-befriend hypothesis to better capture variance in women's stress-response behaviors. The Tend-and-Befriend Questionnaire (TBQ) measures self-reported individual differences in the use of fight, flight, tend, and befriend. Several studie...

Objective: This study aimed to quantify the instability of psychotherapy process variables by using a novel data-analytic approach. The study explored instability of the working alliance over 10 treatment sessions and its relationship with self-esteem. Methods: Data were extracted from a randomized controlled trial, conducted in Switzerland, of...

Attachment theory is a comprehensive and wide-reaching framework for describing humans’ patterns of interacting with significant others, including parents, children, and romantic partners.

Objective: Treatment guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment (American Psychiatric Association, 2010; National Health & Medical Research Council, 2013). However, the current literature suggests that evidence-based treatment fo...

Research shows that increased pursuit of intrinsic goals and decreased pursuit of extrinsic goals are associated with elevated perceived communal behaviors. This preliminary study extends prior research by examining how day-to-day variations in intrinsic (i.e., community feelings) and extrinsic relational goals (i.e., self-image, conformity) link t...

Narcissistic Personality Disorder (NPD) is complex and difficult to treat. Whilst there is no research based evidence for the specific treatment of NPD, there is an evidence base for psychotherapeutic approaches to Borderline Personality Disorder (BPD) which includes Transference Focused Psychotherapy (TFP). TFP is a contemporary object relations a...

The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a popular screening tool for identifying people who may have borderline personality disorder (BPD). However, because women are more frequently diagnosed with the disorder than men, it is possible that the MSI-BPD differs in its ability to identify BPD as a function of...

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the Interna...

Interpersonal theory organizes social behavior along dominant (vs. submissive) and warm (vs. cold) dimensions. There is a growing interest in assessing these behaviors in naturalistic settings to maximize ecological validity and to study dynamic social processes. Studies that have assessed interpersonal behavior in daily life have primarily relied...

The Reading the Mind in the Eyes Task (RMET) is commonly used to assess mentalizing, the capacity to make inferences about mental states. The RMET has been used to examine mentalizing across mental health disorders such as autism, schizophrenia, eating disorders, and schizotypal, borderline, and narcissistic personality disorders. In this meta-anal...

Background: Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive fac...

It is argued that the diagnosis of borderline personality disorder (BPD) is an important clinical concept that has important clinical utility. Factor analytic studies show that its symptoms are regularly associated with each other to form a coherent construct. This chapter provides an overview of BPD, its clinical presentation, and the treatment ap...

Interpersonal theory organizes social behavior along dominant (vs. submissive) and warm (vs. cold) dimensions. There is a growing interest in assessing these behaviors in naturalistic settings to maximize ecological validity and to study dynamic social processes. Studies that have assessed interpersonal behavior in daily life have primarily relied...

In 2000, Taylor and colleagues proposed the “tend-and-befriend” hypothesis, which posits that women utilize an alternative stress response to fight-or-flight, promoting the survival of themselves and their offspring (tend) through the formation of groups (befriend). Although there has been support for this hypothesis since, Levy and colleagues (201...

Treatment approaches for borderline personality disorder (BPD) derive from a range of traditions and theoretical orientations, oftentimes considered to be competing or mutually exclusive. In this chapter we describe the major psychotherapy approaches for treating BPD and examine the evidence from both randomized controlled trials and meta-analyses....

Chronic emptiness in borderline personality disorder (BPD) has received little empirical attention. We sought to examine basic properties of a single chronic emptiness item, including prevalence, reliability, validity, the relation of the emptiness item to other BPD criteria, and measures of personality. Undergraduates enrolled in psychology course...

Objective: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory...

Background Most people will experience a traumatic event in their lifetime, but only a subset (<10%) will develop posttraumatic stress disorder (PTSD). Objective To facilitate prevention and intervention of PTSD, it is important to understand how risk and resilience factors interact with one another to explain individual differences in risk for PT...

Personality disorders (PDs) are relatively common, especially in clinical settings. A number of evidence-based treatments are now available, especially for borderline personality disorder (BPD). However, little is known about the relevant training available to doctoral students in clinical and counseling psychology. In the current study, data were...

To date, prominent theories still disagree on whether the pathological grandiosity that underlies narcissism stems from a defensive, compensatory process in response to insecurity or from years of unjustified overvaluation during formative stages of development. Across two studies, we introduce a novel method to test these theories by examining vis...

In this chapter, we discuss the state of the science regarding the measurement of implicit personality (i.e., the elements of personality that are not accessible via conscious introspection). Optimal measurement of implicit personality necessitates a strong underlying psychological theory combined with indirect measurement that is resilient to dish...

Beginning with its inception in DSM‐III, NPD has been characterized by a pervasive pattern of grandiosity, feeling privileged, entitled, and expecting preferential treatment, as well as displaying an exaggerated sense of self‐importance, and showing arrogant and haughty behaviors or attitudes. In contrast to DSM's predominantly grandiose emphasis,...

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating disorder characterized by instability in one's sense of self, others, and mood. This instability is expressed as emotional lability, impulsivity, interpersonal dysfunction, angry outbursts, suicidality, and non‐suicidal self‐injury. One in 10 patients with BPD wi...

Beginning with its inception in DSM‐III, NPD has been characterized by a pervasive pattern of grandiosity, feeling privileged, entitled, and expecting preferential treatment, as well as displaying an exaggerated sense of self‐importance, and showing arrogant and haughty behaviors or attitudes. In contrast to DSM's predominantly grandiose emphasis,...

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating disorder characterized by instability in one's sense of self, others, and mood. This instability is expressed as emotional lability, impulsivity, interpersonal dysfunction, angry outbursts, suicidality, and non‐suicidal self‐injury. One in 10 patients with BPD wi...

Experience sampling methods are widely used in clinical psychology to study affective dynamics in psychopathology. The present study examined whether affect ratings (valence and arousal) differed as a function of assessment schedule (signal- versus event-contingent) in a clinical sample and considered various approaches to modeling these ratings. A...

This study investigates the “tend-and-befriend” hypothesis proposed in 2000 by Taylor and colleagues, which posits that women utilize an alternative stress response to fight-or-flight, ensuring the survival of themselves and their offspring (tend) through the formation of groups (befriend). In contrast, we propose that, while sexes may differ in th...

Purpose of Review In this article, we describe the goals of transference-focused psychotherapy (TFP), its indications, underlying theory, and its broad structure and techniques. We summarize the current empirical support for TFP in regard to symptom and personality change. Lastly, we discuss recent developments and applications in TFP. Recent Find...

Borderline personality disorder (BPD) involves instability in self-concept, emotions, and behavior. However, the dynamic, longitudinal relations among BPD symptoms and between these symptoms and other problematic emotional experiences are poorly understood. It is also unclear whether these dynamics are the same across persons (including across diag...

Childhood maltreatment is one of many risk factors for borderline personality disorder (BPD). However, not all individuals with BPD report histories of childhood maltreatment. Therefore, it is necessary to identify factors that contextualize the relation between childhood maltreatment and BPD features. With its emphasis on the developmental origins...

Objective: To examine conformity to prototypical therapeutic principles and its relation with change in reflective functioning in 3 treatments for borderline personality disorder (BPD). Method: Early phase videotaped sessions from a randomized-controlled trial of year-long transference-focused psychotherapy (TFP; n = 27), dialectical behavior th...

Objective: Borderline personality disorder (BPD) is serious, prevalent, and symptomatically heterogeneous. Identifying distinct phenotypes of BPD features promises useful diagnostic and treatment implications. Although a series of subtyping studies exist, only two have examined BPD symptom configurations while taking into account BPD severity. We u...

Attachment style describes characteristic patterns of relating to close others and has important implications for psychotherapy. This chapter provides an original meta-analysis of 36 studies (3,158 patients) to determine the association of patient attachment with psychotherapy outcome. Patients with secure attachment pretreatment show better psycho...

Psychotherapy Relationships That Work is the definitive, evidence-based book on the psychotherapy relationship: what works in general (Volume 1) and what works for particular patients (Volume 2). Each chapter presents definitions, clinical examples, landmark studies, comprehensive meta-analyses, diversity considerations, and training implications a...

Objective: To examine if alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Method: Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOT...

Transference-focused psychotherapy (TFP) is a psychodynamic, empirically supported psychotherapy for personality disorders based on Otto Kernberg's object relations theory. Case formulation and treatment planning in TFP is based on the patient's level of personality organization (i.e., capacity for reality testing, predominant defence mechanisms, a...

Findings from randomized controlled trials and meta-analyses suggest that there are several efficacious treatments for borderline personality disorder, including those based on cognitive behavior theories and psychodynamic theories. In addition, there are generalist and adjunctive approaches. These treatments and the corresponding evidence associat...

In this paper, we provide an overview of Bowlby’s theory of attachment, its revisions, and related constructs, and describe how attachment may underlie many of the processes of psychotherapy. Modern psychotherapy research, plagued by the omnipresent “dodo bird” that has consistently determined that most psychotherapy modalities appear to have simil...

Bowlby’s attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta‐analysis to...

Psychotherapy for personality disorders – a group of disorders characterized by long-standing patterns of intra- and interpersonal difficulties – tends to be highly structured, integrative, and often long-term, with special attention made to the relationship between therapist and patient.

The founding members of the Coalition for Psychotherapy Parity present Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity. These guidelines support access to psychotherapy as prescribed by the clinician without arbitrary limitations on duration or frequency. The au...

Deficits in identity as well as negative affect have been shown to predict self-injurious and suicidal behaviors in individuals with borderline personality disorder (BPD). However, less is known about the interactive effects of these two predictors. We examined the moderating effect of a particular component of identity, self-concept, on the relati...

In this study, the authors explored whether attachment insecurity moderates the effects of adverse childhood experiences on stress reactivity in the context of borderline personality disorder (BPD). Participants were 113 women (39 with BPD, 15 with some BPD criteria present, 59 without any BPD symptoms) who participated in the Trier Social Stress T...

Transference-focused psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. Similar to other psychodynamic psychotherapies, TFP focuses on changing psychological structures, but also focuses on symptom and behavioral change, particul...

This study examines psychopathology and clinical characteristics of patients with borderline personality disorder (BPD) and comorbid narcissistic personality disorder (NPD) from two international randomized controlled trials. From a combined sample of 188 patients with BPD, 25 also fulfilled criteria for a comorbid diagnosis of NPD according to DSM...

Personality disorder not otherwise specified (PDNOS) is a diagnostic category describing problems with inter and intrapersonal functioning (i.e., personality disorder) that are not accounted for by the specific personality disorder diagnoses defined by the DSM and ICD.

Case Studies Within Psychotherapy Trials: Integrating Qualitative and Quantitative Methods presents a specific, mixed-methods approach, called the “Cases Within Trials” (CWT) model, to psychotherapy research combining the results from a randomized clinical trial (RCT); the results of richly and qualitatively detailed systematic case studies involvi...

Personality disorders are a heterogeneous group of mental disorders which arise when an individual’s personality is considered impaired and maladaptive. As will be discussed in greater detail below, personality disorders (PDs) are highly prevalent in the general population (up to 18%) and much higher in patient populations (up to 75%). In addition...

Objective: We differentiated two hypothesized client subtypes: (a) Pseudosecure clients have high Client Attachment to Therapist Scale (CATS) Secure and high CATS Preoccupied scores, tend to idealize their therapist, and exhibit maladaptive dependency; (b) Individuated-secure clients combine high Secure with low Preoccupied scores and function mor...

Patients with personality disorders (PDs) represent a particular burden for the health system and the clinicians attempting to treat them. The current commentary complements reviews of outcome studies on treatments for PDs by focusing on the clinical utility as defined by the American Psychological Association. As such, extending that notion, clini...

AimBorderline personality disorder (BPD) is characterized by self-regulation deficits, including impulsivity and affective lability. Transference-Focused Psychotherapy (TFP) is an evidence-based treatment proven to reduce symptoms across multiple cognitive-emotional domains in BPD. This pilot study aims to investigate neural activation associated w...

The Client Attachment to Therapist Scale (CATS) assesses three dimensions of attachment between client and therapist: Secure, Avoidant, and Preoccupied. Clients with high Preoccupied scores tend to exhibit a maladaptive dependency on their therapist. The tendency of some of these clients to simultaneously idealize their therapist while they fear ab...

Individuals with borderline personality disorder (BPD) display an impoverished sense of self and representations of self and others that shift between positive and negative poles. However, little research has investigated the nature of representational disturbance in BPD. The present study takes a multimodal approach. A card sort task was used to i...

In this paper we propose that John Bowlby's attachment theory provides a theoretically coherent, empirically based, and clinically useful model for understanding personality pathology. This theoretical framework brings parsimony and breadth to the conceptualization of the etiology, maintenance, and treatment of personality disorders (PDs). Attachme...

Personality disorders are highly prevalent, associated with considerable morbidity, and difficult to treat. Intrapersonal and interpersonal difficulties are central to the pathology observed in personality disorders. Attachment theory provides a broad yet parsimonious explanatory framework for understanding the development, maintenance, and treatme...

Despite the articulation and growing evidence for shared properties in effective psychotherapies and the value of integrated protocols, the training and the provision of psychotherapy are becoming increasingly monothetic. This movement toward monocultures is in contrast to the development of a comprehensive and integrative theory of psychotherapy t...

We investigated attachment representations and the capacity for mentalization in a sample of adult female borderline patients with and without comorbid narcissistic personality disorder (NPD). Participants were 22 borderline patients diagnosed with comorbid NPD (NPD/BPD) and 129 BPD patients without NPD (BPD) from 2 randomized clinical trials. Atta...

Abstract The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific...

Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in t...

Borderline personality disorder (BPD) and major depressive disorder (MDD) share numerous features, including dysphoric affect, irritability, suicidality, and a heightened sensitivity to perceived interpersonal rejection. However, these disorders are associated with divergent profiles of reactivity to rejection: Individuals with MDD are more likely...

To characterize predominant typologies of co-occurring personality disorders among adults with posttraumatic stress disorder (PTSD) and examine their relation to Axis I comorbidities, health-related quality of life, and course and treatment of PTSD. Latent class analysis was conducted on the 10 DSM-IV personality disorders in a nationally represent...

Whereas some individuals with personality disorders experience intense desires for emotional closeness, others find emotional closeness difficult and distressing. Regardless, those with personality disorders are often characterized by experiences of loneliness, isolation, and distressing solitude. Despite this phenomenological experience, surprisin...

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experie...

In this introduction to the JCLP: In Session 69(11) issue on attachment theory and psychotherapy, the key points of attachment theory (Bowlby, , , 1981) and its relevance to psychotherapy are briefly described. The aim of this issue is to provide case illustrations of how an attachment theory perspective and principles can expand our understanding...

Transference-Focused Psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. The treatment contracting/setting the frame, managing countertransference, and the interpretative process are three critical components of TFP. We provide vi...